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A Department of Veterans Affairs drug rehabilitation facility was so poorly run that some patients were actually on drugs during their stay there — culminating in the death of a veteran from an overdose of cocaine and heroin.

According to an investigation conducted after the veteran’s death, inspectors found that workers at the Department of Veterans Affairs Medical Center in Miami, Fla., often spent their evening, night and weekend shifts in a back room instead of monitoring patients, and that the facilities surveillance camera systems weren’t working.

The staff didn’t monitor where patients went and did not search them upon their return, said the report released Friday by the VA’s inspector general. The lax practices allowed patients to repeatedly take drugs and likely bring them into the VA facility, the watchdog said.

One Afghanistan combat veteran in his 20s left the rehabilitation center for a day trip. Upon his return, a nurse marked down “bag(s) checked: no.” Investigators were uncertain whether that meant medical staff had not checked his bags, or if the patient had no bags to check.

The next morning he was found dead from a drug overdose.

During their investigation, the inspector general found that an additional seven patients out of 21 tested positive for drugs, while another five also tested positive, though investigators noted in those cases it could have been prescribed medication which gave a false reading.

Access to the facility was poorly monitored, and investigators noted they were able to walk in without having to show any credentials or tell anyone who they were.

Officials at the Miami medical center said they have already fixed the problems highlighted in the report, and are continuing to monitor employees to ensure they watch patients, conduct searches for illegal drugs and test veterans for continued drug use.

“For veterans with a history of substance abuse, at least one [drug screening] will be collected upon return from any weekend pass, and at least one additional screen will be collected during the week at a random time,” a response from the medical center said.

Meanwhile the facility’s camera system is mostly up and working, but will be upgraded by August.

The medical center is in an area of Miami with a reported high drug use, and “patients who are allowed to leave the unit unsupervised have potentially easy access to illicit drugs,” the inspector general’s office said.

Although investigators stopped short of laying blame for the veteran’s death, they said that the medical center was not following “policies that help establish a safe and secure environment.”

The VA report comes as Sen. Bill Nelson, a Florida Democrat, is visiting a veterans’ facility in Tampa to investigate other questionable deaths. Mr. Nelson also wrote a letter to Veterans Affairs Secretary Eric K. Shinseki, who has been accused by lawmakers in both the House and Senate of stonewalling investigations into agency wrongdoings.

“Congress’ oversight authority is greatly aided by the willing transparency of an agency as large as the VA.,” Mr. Nelson wrote. “The published accounts I’ve seen indicate that work still needs to be done to achieve this level of transparency and I ask you to re-energize those efforts.”

Veterans Affairs Committee Chairman Jeff Miller, a Florida Republican, has launched a website designed to track all the times the VA doesn’t answer questions from Congress or the press.

“VA’s media-avoidance strategy can’t be anything other than intentional,” Mr. Miller said in a statement. “What’s worse, the tactic leaves the impression that department leaders think the same taxpayers who fund the department don’t deserve an explanation of the VA’s conduct.”